1. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). HEDIS OPERATIONS HEALTHCARE OUTCOMES & ANALYSIS 1 HEDIS ® Made Easy What you really need to know Disclaimer “This document is merely a tool for providers and provides a general summary on some limited HEDIS® Program requirements. This document should not be used as legal advice or expert advice or comprehensive summary of the HEDIS ® Program. Please refer to ncqa.org for HEDIS ® Program measures and guidelines as well as relevant statutes. The information provided is in this document is for 2016 HEDIS period and is current at the time this document was created. NCQA HEDIS ® Program requirements, applicable laws, and L.A. Care’s policy change from time to time, and information and documents requested from you may also change to comply with these requirements L.A. Care is not affiliated with NCQA or its HEDIS ®Program and does not receive any financial remuneration from it.”

2. Learning Goals for Today  HIPAA  Learn what HEDIS® is  What is your role in HEDIS®?  Annual HEDIS® Calendar  Medical Record Requests  Hybrid HEDIS® Measures  Questions & Answers 2

3. Our “1” Simple Goal HEDIS® can be intimidating HEDIS® can be nerve wracking HEDIS® can be frustrating To make HEDIS® easier for you! 3

4. How to Reach Goals Understand the guidelines Follow best practice Establish a habit Continual repetition till it sticks 4

5. HIPAA Under the Health Information Portability and Accountability Act rule: Personal Health Information (PHI) can be collected and shared with the Health Plan for quality purposes Data collection is permitted No further authorization needed from the patient 5

6. What is HEDIS®? Healthcare Effectiveness Data and Information Set 6

7. Retrospective Review HEDIS® is a look backwards at the year or year(s) prior It is a review of the services and clinical care provided to L.A. Care patients. 7 Future Past

8. HEDIS® HYBRID DATA HEDIS® hybrid data is a combination of: 1.Administrative data: Data captured from Claims, Encounters, Pharmacy, and Labs 2.Medical Record review: A validation audit 8

9. What is your role in HEDIS®? Ensure preventative healthcare screening is done Ensure screening is completed within the right time frame Ensure all screenings are documented in the Medical Record Ensure the date of service, date of birth, and member name are legible and correct Faxing medical records to L.A. Care within 5 business days of request 9

10. HEDIS® 2016 CALENDAR 10 Jan – May June July - Oct Collection of medical records from Dr. Offices Medical records audited by L.A. Care Audit results are compiled Audit results are sent to NCQA NCQA releases report card NCQA releases new measures/changes Training at doctors’ offices Onsite medical record audit

11. Medical Record Requests Medical record requests are sent by fax and include: A patient list The measure(s) we are auditing Explanation of the minimum documents needed 11

12. Frequently Asked Questions Should I send the entire record? No, we ask that you only provide what is needed which is specified on the medical request form Who do I contact if I have a question about the HEDIS® request? Each fax request sent includes the contact person’s name and telephone number 12

13. Turn-Around Time 13 Day turn-around to fax Medical Records to L.A. Care

14. Hybrid HEDIS® Measures 14 Line of BusinessAdult Health Medi-CalLACCMA ABA Adult BMI Assessment Medi-CalLACCMAMMP CBP Controlling High Blood Pressure Medi-CalLACCMA CDC Comprehensive Diabetes Care MAMMP COL Colorectal Cancer Screening MLTSSMAMMP MRP Medication Reconciliation Post Discharge Older Adult Health MAMMP COA Care for the Older Adults Women's Health Medi-CalLACC CCS Cervical Cancer Screening Medi-Cal FPC Frequency of Prenatal Care Medi-CalLACC PPC Prenatal and Postpartum Care Children and Adolescent Health Medi-CalLACC CIS Children Immunization Status Medi-CalLACC HPV Human Papillomavirus Vaccine for Female Adolescents Medi-CalLACC IMA Immunizations for Adolescents Medi-CalLACC WCC Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Medi-Cal W34 Well-Child Visits in the 3rd, 4th, 5th & 6th Years of Life Medi-Cal AWC Adolescent Well-Care Visits MMP – Cal MediConnect/dual eligible; MA – Medicare Advantage; LACC – Commercial/Marketplace; MLTSS – Managed Long Term Services and Support

15. ADULT HEALTH 15 Hybrid HEDIS® MEASURES

16. Adult BMI Assessment (ABA) 16 Documentation must have:  20 years-of-age and Older: Weight and BMI value.  Younger than 20 years-of-age : Height, Weight, and BMI in Percentile. Common Chart Deficiencies: Height and/or weight are documented but there is no calculation of the BMI A range was given or threshold to be met. Each patient must have a distinct BMI value or % Ages 18-74 Documentation in 2014/2015

17. Controlling High Blood Pressure (CBP) 17 Documentation must have: HTN Diagnosis before June 2015 Last BP reading of 2015 You must have the date and result Common Chart Deficiencies: Elevated BP Check the patient’s BP at the beginning and the end of the visit and document both findings Diagnosis date of hypertension is not clearly documented A minimum of two notes must be submitted. 1) HTN Diagnosis 2) BP reading The Diagnosis can be from any progress note, problem list, consult note, hospital admission or discharge Ages 18-85 Diagnosis of Hypertension Blood Pressure Controlled 18-59 <140/90 60-85 with diabetes < 140/90 60-85 without diabetes < 150/90

18. Comprehensive Diabetes Care (CDC) 18 Documentation must have: Common Chart Deficiencies:  Tests ordered but not done  Lab results not found  Consult reports not found  BP reading elevated. Take BP reading at the beginning and end of each visit, and document Hemoglobin A1c Blood Pressure Nephropathy: Urine Tests (+) and (-) now acceptable, ACE/ARB prescription, or visits notes from nephrologists Retinal Eye Exam (2014/2015) Submit the last HbA1c and BP screening of the year 2015 Ages 18-75 HbA1c Testing HbA1c Results Nephrology Retinal Eye Exam Blood Pressure reading

19. 19 Colorectal Cancer Screening (COL) Documentation must have: Date and result of one of these screenings: Colonoscopy within ten years (2006 -2015) Sigmoidoscopy within five years (2011-2015) FOBT (in 2015) Any of the three scenarios pass for FOBT 1.Guaiac FOBT – 3 samples or note that done 2.Immunochemical FOBT note that it was done 3.FOBT unknown but documented as done Common Chart Deficiencies: Not documenting Colorectal screenings in the health history Not providing the health history with the note and/or test results FOBT test performed in an office setting or performed during a digital rectal exam do not meet criteria Ages 50-75 Screening for Colon Cancer

20. 20 Medication Reconciliation Post-Discharge (MRP) Documentation must have: 1.Notation that the medications prescribed upon discharge were reconciled with the current medication in the outpatient record -or- 2.A medication list in a discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications -or- 3.Notation that no medications were prescribed upon discharge Ages 18 + Medication reconciliation conducted by a prescribing practitioner, clinical pharmacist or registered nurse on date of discharge through 30 days after discharge (31 days total) An outpatient visit is not required, only documentation in the outpatient record that the medication was reconciled meets criteria

21. 21 OLDER ADULT HEALTH Hybrid HEDIS® MEASURES

22. 22 Documentation must have: 1. Advance care planning Includes a discussion about preferences for resuscitation, life sustaining treatment and end of life care. Examples include: Advance directives Actionable medical orders Documentation of care planning discussion Living Will 2. Medication review Includes at least one (1) medication review with: Presence of a medication list and date the review was performed or Dated notation that the member is not taking any medication Review must be by a prescribing practitioner and/or pharmacist Care of the Older Adult (COA) Ages 66 + Advance Care Planning Medication Review Functional Status Assessment Pain Assessment

23. 23 Documentation must have: 3. Functional status assessment One (1) functional status assessment and the date it was performed Notation ADLs were assessed, or Notation that Instrumental Activity of Daily Living (IADL) were assessed, or Results of assessment using a standardized tool, or Notation that at least 3 of the 4 following were assessed: cognitive status, ambulation status, hearing, vision and speech, other functional independence The assessments may be done during separate visits 4. Pain assessment Documentation of pain assessment and the date it was performed (Positive or Negative findings) Care of the Older Adult (COA) (Continued)

24. 24 WOMEN’S HEALTH Hybrid HEDIS® MEASURES

25. 25 Documentation must have: Date and result of cervical cancer screening test -or- Date and result of cervical cancer screening test and date of HPV test on the same date of service -or- Evidence of hysterectomy with no residual cervix Common Chart Deficiencies: Pap Smear test results not found in PCP charts Incomplete documentation related to hysterectomy Females Ages 21-64 Pap (2013/2014/2015) Females Ages 30-64 Pap with HPV co-testing results (2011–2015) Cervical Cancer Screening (CCS) HPV ordered after positive Pap testing does not count as co-testing

26. 26 Documentation must have: Date and documentation of all prenatal visits Most of this information is found on the ACOG form ACOG recommends 14 visits for a 40 week pregnancy Common Chart Deficiencies: Must be “unduplicated” prenatal visits. If there is an office visit and the provider orders an U/S and labs and they are done on separate days, all three would only count as one date of service. Frequency of Ongoing Prenatal Care (FPC) Live Births Delivered on or between 11/6/2014 to 11/5/2015 and were continuously enrolled 42 days prior to delivery

27. 27 Documentation must have: Prenatal Care: Prenatal visit during the first trimester or within 42 days of enrollment Most information is found on the ACOG form Postpartum Care: Post-partum visit within 21-56 days of delivery Common Chart Deficiencies: Prenatal care not done within timeframe No Postpartum care visit Incision check for post C-section does not constitute a postpartum visit Prenatal and Postpartum Care (PPC) Live Births Delivered on or between 11/6/2014 to 11/5/2015

28. 28 CHILD AND ADOLESCENT HEALTH Hybrid HEDIS® MEASURES

29. 29 Childhood Immunization Status (CIS) Documentation must have: Submit: Complete Immunization Records PM 160 CAIR Records Copy of yellow immunization card Parental refusal Allergies List History of Illness, as applicable % of children 2 years of age who had all of the required immunizations (2013-2015) 4 Dtap Diphtheria, tetanus and cellular pertussis 3 IPVInactivated Polio Virus 1 MMRMeasles, Mumps, and Rubella 3 HibHaemophilus influenza type B 3 HepBHepatitis B 1 VZVChicken Pox 4 PCVPneumococcal conjugate 1 HepAHepatitis 2 or 3 RVRotavirus 1 FluInfluenza

30. 30 Common Chart Deficiencies: Immunizations received after the 2nd birthday PCP charts do not contain immunization records if received at Health Department or school. Immunizations records given in the hospital at birth are not obtained No documentation of allergies or contraindications No documentation of parental refusal Childhood Immunization Status (CIS) ( Continued) If missing any immunizations, please include: Documentation of parental refusal Documentation of request for delayed immunization schedules Immunizations given at health departments Immunizations given in the hospital at birth Documentation of contraindications or allergies

31. 31 Documentation must have: At least (3) three HPV vaccinations with different dates of service. Submit: MD Progress note, PM 160, Copy of immunization record, CAIR Record If immunizations are missing please send: Documentation of parental refusal Copy of Immunization card Patient Contraindications/allergies Common Chart Deficiencies: HPV vaccines administered prior to the 9th birthday or after the 13 th birthday PCP charts do not contain immunization records if received elsewhere, i.e. Health Departments and schools. Immunizations not documented Parental refusal not documented Human Papillomavirus Vaccine (HPV) Female adolescent 3 doses of the HPV vaccine by age 13 2011 – 2015 between the 9 th and 13 th birthdays

32. 32 Immunizations for Adolescents (IMA) Documentation must have: Date administered and type Certificate of immunization Notation of anaphylactic reaction If immunizations are missing please send: Documentation of parental refusal Patient Contraindications/allergies Common Chart Deficiencies: Immunizations not administered during timeframes Immunization records not found in the PCP chart or Immunization card Meningococcal 2013 – 2015 (11th - 13th birthday) Tdap or Td 2012 – 2015 (10th - 13th birthday)

33. 33 Documentation must have: BMI date and percentile Weight date and value Height date and value Age growth chart(s) BMI Value option removed for members ages 16-17, must be in percentile only Ages 3-17 Notation in the medical record Year 2015 Counseling for Nutrition: Documentation of discussion on diet and nutrition, checklist, referral to nutritionist, anticipatory guidance, or weight/ obesity counseling Counseling for Physical Activity: Documentation of discussion on current physical activities, check list, counseling/referral, education, anticipatory guidance, or weight/ obesity counseling Weight Assessment & Counseling for Nutrition & Physical Activity for Children/Adolescents (WCC)

34. 34 Common Chart Deficiencies:  BMI documented as value (number) not as percentile  BMI growth charts not submitted  Anticipatory guidance does not always address nutrition and physical activity  Developmental milestones are not acceptable  PM 160 forms do not address physical activity Weight Assessment & Counseling for Nutrition & Physical Activity for Children/Adolescents (WCC)

35. 35 Well Child Visits in the 3 rd, 4th, 5 th & 6th Years of Life (W34) Documentation must have: Health history Developmental history - physical Developmental history - mental Physical exam Health education/anticipatory guidance Preventive services may be rendered on visits other than well-child visits Common Chart Deficiencies: Lack of documentation of required elements Children being seen for sick visits and the required elements are not addressed Ages 3 -6 yrs. At least ONE “Well-Child” visit with a PCP in 2015

36. 36 Adolescent Well-Child Visits (AWC) Documentation must have: Health history Developmental history physical Developmental history mental Physical exam Health education/anticipatory guidance Preventive services may be rendered on visits other than well-care visits. Common Chart Deficiencies: Lack of documentation of required elements Adolescents being seen for sick visits and the required elements are not addressed Ages 12 - 21 yrs. At least one “Well-Child” visit with a PCP or an OB/GYN in 2015

37. 37 Let’s See What You’ve Learned 1.What does HEDIS® Stand for? 2.What is your role in HEDIS®? 3.Do you need to send the entire record? 4.What do you do if you have questions?

38. 38 Got Questions? Email us at: HEDIS_Ops@lacare.org Check out our website at: https://www.lacare.org/providers/provider-resources Click on: HEDIS® Resources For helpful trainings and guides

39. 39 Resources at Your Fingertips Presentation and Trainings: HEDIS® Overview Presentation WCC – Weight Assessment Documentation HEDIS® Made Easy Guidance Documents: HEDIS® 2016 Measure Criteria HEDIS® at a Glance HEDIS® Measures Handout HEDIS® Measures Poster HEDIS® Office Manager’s Guide Provider Opportunity Report HEDIS® Value Set Directory

40. Question and Answer Period HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). HEDIS OPERATIONS HEALTHCARE OUTCOMES & ANALYSIS 40

41. 41 THE END HEDIS® Made Easy 2016